In the current report, the existing level of HIV knowledge and attitudes was assessed and the effectiveness of two educational approaches in improving the level of HIV awareness was prospectively compared. Our baseline data suggested the existence of ample room for basic HIV knowledge improvement in all three villages. For a majority of the questions (6 out of 10), the correct response rates at baseline were less than 70%. Less than a third of the respondents provided the appropriate response to the question regarding the mode of HIV transmission. Factors associated with lower HIV awareness in our sample were gender, lack of formal education, and the community. These findings are important in part because women represent the fastest growing segment of the AIDS epidemic in many regions of the world, particularly in sub-Saharan Africa where over half of the disease burden is borne by females .
The results of our longitudinal assessment indicate that the implementation of an integrated audio program that accommodates the local learning culture is feasible and effective in enhancing HIV awareness in the rural setting. Appreciable and statistically significance changes in HIV knowledge were observed from baseline to week 7 following the integrated campaign compared with the control program of seminar/pamphlet distribution. Although the conventional approach of seminars and pamphlet distribution resulted in some amount of improved HIV awareness, the audio-device assisted intervention was associated with a more robust gain in knowledge for all but two (D and E) of the ten HIV knowledge questions. We attribute this gain to the multi-faceted approach employed in this intervention; the content was formatted into culturally-familiar oral modules and was delivered in a small group setting in the local language, by an easy-to-use audio platform. The use of an mp3-like device ensured that information was consistent and participants could refresh their knowledge by listening multiple times. Pamphlet distribution and large group seminars are widely used in HIV education in resource-limited settings, due to ease and their low cost. However, our data suggests that this approach was suboptimal compared to our novel audio approach. In the large group settings of group seminars, individuals tend to be less inclined to ask questions to clarify doubts. Furthermore, the impact of the pamphlets in rural settings is limited by low literacy. Pamphlets read during a visit by individuals unknown to the community are also unlikely to stimulate sustained discussion of the information.
Additionally, it was encouraging to find that the improvement in the level of HIV knowledge was sustained through the second assessment at week 14. Yet we had anticipated a greater gain in knowledge for the intervention group at week 14, as the delivery audio devices were left behind for subjects to replay and potentially reinforce learned messages. A number of factors may have accounted for this plateau, including learning saturation and fatigue from listening to the same content repeatedly, and inadequate time between assessment periods. Future work could include memory chips with multiple versions of the message, with variations of the songs, proverbs, parables and dramas, which could help to reduce fatigue.
Being male and having some education posed some advantage in this conservative Muslim society. Yet, regardless of subjects' gender or education status, improvements in HIV knowledge were observed across all segments of the population, supporting the value of this integrated approach as an effective mode of delivering information across demographics in these communities. The poll of audio program reach in the intervention villages indicated that device listening had proliferated in the community far beyond the original cohort of study participants. Admittedly, the convenience sampling method was suboptimal and future studies might prospectively plan to quantify program exposure throughout the community. The cost-effectiveness of deploying the digital audio outreach program in the intervention communities is noteworthy. The cost per individual educated by this intervention (including content development, technology, training and distribution), was less than US $3. This is extremely modest when compared to the cost person reached of $67 reported for HIV outreach program to prostitutes in Cameroon , and the estimated cost of TV and radio emission of $2566 and $383 per minute respectively .
Our study was limited by a number of factors including selection bias from the non-randomized selection of the communities, districts and individual participants. The follow-up of 14 weeks was rather short to assess long-term retention of HIV knowledge. Other designs (cluster trials) and sampling plans with longer follow-up should be considered when planning future studies of education outreach programs in this setting. Furthermore, the use of the same assessment instrument for all three visits may have altered patients' responses at follow-up. Future studies should consider incorporating a larger pool of questions, with several questions testing similar domains of knowledge. An assessment of the communal reach of the seminar and pamphlet program in the control village would have provided for a more robust comparison of the two intervention groups. Behavioral change resulting from knowledge gained was not directly measured; subsequent work might assess knowledge retention vis-à-vis behavior modification at later time points after program exposure.